Acetaminophen Underused in Acute Sports Injuries, Expert Says

This post originally appeared on MedPage Today: Pain Management.

NATIONAL HARBOR, Md. — Sports injuries are often treated incorrectly, and there is not enough use of a common pain reliever: acetaminophen, Brian Hainline, MD, chief medical officer of the National Collegiate Athletic Association, said here Friday.

“Acetaminophen is vastly, vastly under-prescribed acutely, because in fact the loading dose is 2,000 mg,” he said at the annual meeting of the American Academy of Pain Medicine. “When we looked at the literature, acetaminophen and, if it’s appropriate, an anti-inflammatory drug, they actually can augment one another, and when someone has pain and they want to continue to compete the same day, and you don’t want to give them a narcotic and it’s biomechanically safe for them to do so, acetaminophen is actually a great idea.”

What about opiates? “It’s very rare now that sports medicine physicians are giving opiates for musculoskeletal pain, and when we do, it usually is not done beyond 3 days,” because the likelihood of developing chronic opioid use increases every day after that, Hainline explained.

In addition, he said, “medicine should never be used for pain or injury prevention. But let me tell you something — go to an ultra-distance race as a physician … and see what people are putting into their stomachs. They’re pre-loading with NSAIDs [non-steroid anti-inflammatory drugs], and we know that is not efficacious and we now have very good evidence that is dangerous. But this is what the athletes are doing, and when we took a survey of Olympic physicians in Rio, up to 15% were prescribing non-steroidals before competition.”

What really works for managing pain in athletes is movement, said Hainline, “but the movement is based on proper movement, and the evidence is overwhelming that once we move into strengthening and conditioning, that’s the best non-pharmacologic treatment we can offer our athletes,” with isometric exercises in particular possibly being the most effective pain management strategy, he said.

Acetaminophen is underused in acute sports injuries, according to Brian Hainline, MD, chief medical officer of the National Collegiate Athletic Association. (Photo by Joyce Frieden)

Psychosocial interventions are also key, according to Hainline. “There is good evidence that if you have a perfectly biomechanically reconstructed ACL [anterior cruciate ligament] and you develop clinical depression during the post-op period, the chance of that ACL repair becoming dysfunctional is statistically significantly greater than if you do not develop clinical depression,” he said.

“Athletes are human beings; they’re young kids,” he added. “The things that make them depressed and anxious are the same things that make all other students depressed or anxious — they broke up with their girlfriend or boyfriend, they flunked out of a test, they’re having trouble with finances. Also, when they’re hurt, and they fear they’re going to transition out of a sport, it’s their most vulnerable time, and it’s a time when we’ve seen the worst mental health outcomes. When they are catastrophizing, when they are profoundly depressed, that has a huge impact on pain.”

The two things that are most important in dealing with athletic injuries are taking a good history and giving a biomechanical exam, Hainline said. He gave the example of an 18-year-old patient, a baseball player with chronic elbow pain; the player had seen multiple physicians and was under great pressure to get a baseball scholarship.

“His history was, he was actually playing in three different leagues and none of the other leagues knew about it,” said Hainline. “He had three different coaches. There is a pitch count in baseball and he was way over the pitch count, so he was severely overtraining … and the only one who knew was the parent who was pushing him to extremes.”

Another patient Hainline treated was tennis great Pete Sampras. In 1999, Sampras was in line to break the men’s singles Grand Slam record at the U.S. Open, “but before the tournament, he was warming up, and he just did a simple backhand, and developed severe pain” in his back, “exactly in the midline, at the L-4 level,” Hainline said.

“What can give you pain exactly in the midline? His exam only had one abnormality — when he bent forward, the pain accentuated,” although he was fine with side movements, he said. “What I thought was that he had an acute annular tear … That was the only thing that made sense, and I told him that.”

Sampras then went to see another physician, who gave him an epidural without taking an x-ray or anything else. He “sheepishly” gave Hainline a call and mentioned the epidural, “and I said, ‘I can make you pain free for this tournament but the question is, are you going to be able to play again?’ So we did an MRI and he had an unequivocal acute annular tear, and he withdrew from the Open. But he did get back to playing and in 2000, he won Wimbledon, and in 2002 he won the U.S. Open and then he retired. So epidurals can be done … but what are we thinking about the athlete’s health?”

There’s another thing physicians should not do when treating athletes, Hainline said. “I fired three physicians for the same reason: they asked an athlete for an autograph. Once you objectify an athlete, you are no longer an athlete’s physician, and you are no longer able to have that athlete trust you.”

This post originally appeared on MedPage Today: Pain Management.